An index of differential diagnosis of main symptoms / by various writers ; edited by Herbert French.

Date:
1912
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Licence: Public Domain Mark

Credit: An index of differential diagnosis of main symptoms / by various writers ; edited by Herbert French. Source: Wellcome Collection.

    17/1072
    ND EC) Deke Hina vale. DLAGNOSb> OP NIATN SY MPLOMS ACCENTUATION OF HEART SOUNDS.—It often happens that, without there being any cardiac bruit, one or other of the heart sounds is much louder than it ought to be. Such accentuation generally has important clinical sig- nificance. Roughly speaking, it is the first sound that is likely to be either accentuated or prolonged at the impulse ; whilst in the second right, or second and third left intercostal spaces close to the sternum, it is the second sound that is likely to be accentuated rather than the first. It is very unusual to find the first sound accentuated at the base or the second sound at the impulse, unless there is at the same time still greater accentuation of the first sound at the impulse, and of the second sound at the base respectively. Hence the three conditions under which accentuation of a cardiac sound becomes clinically important are: (1) When the second sound is unduly loud in the second right intercostal space close to the sternum; (2) When there is an accentuation of the second sound with maximum intensity in the second or third left intercostal space close to the sternum; (3) When there is accentuation of the first sound with maximum intensity at or near the impulse. Accentuation of the second sound with maximum intensity in the second right intercostal space close to the sternum nearly always indicates that the systemic blood-pressure is above the normal. The latter can only be determined with certainty by actual measurement of the systemic blood-pressure instrumentally. The causes of the increase will probably be one or other of the following :— Age.—Even healthy patients over forty begin to show a slight but definite increase Of BLOOD-PRESSURE (q.v.) as the years go on. In people over fifty, therefore, the aortic second sound begins to get relatively louder than the first. Arteriosclerosis or granulay kidney. These can be discussed together, because it is extremely difficult to tell where the one ends and the other begins. In both there is cardiac hypertrophy, increase in the blood-pressure, prolongation of the first sound at the impulse, and possibly a blowing systolic bruit there, a ringing or clanging aortic second sound which may ultimately change into the diastolic puff of slight aortic regurgitation, albuminuria, a tendency to heart failure as time goes on, with all its concomitant symptoms, and albuminuric retinitis. It is sometimes stated that the accentuation of the aortic second sound is due to local atheroma; but this is inaccurate, for atheroma by itself, though it may easily produce an aortic systolic bruit, does not accentuate the second sound ; and when in the second right intercostal space there is a soft systolic
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